The Mandate Returns

During the primary campaign, one of the big disagreements between Barack Obama and Hillary Clinton was about healthcare mandates. Should a national healthcare plan require that everyone be covered one way or another, or should coverage be optional? Clinton favored a mandate and Obama didn't, but Ezra Klein has been talking to some of the Obama folks involved in formulating the upcoming budget and says that things have changed:

The budget — and I was cautioned that the wording "is changing hourly" — will direct Congress to "aim for universality." That is a bolder goal than simple affordability, which can be achieved, at least in theory, through subsidies. Universality means everyone has coverage, not just the ability to access it. And that requires a mechanism to ensure that they have it.

Administration officials have been very clear on what the inclusion of "universality" is meant to communicate to Congress. As one senior member of the health team said to me, "it will cover everybody. And I don't see how you cover everybody without an individual mandate." That language almost precisely echoes what Senate Finance Chairman Max Baucus told me in an interview last summer. "I don’t see how you can get meaningful universal coverage without a mandate," he said. That judgment was further emphasized last fall, when he released the first draft of his health care plan and built in an individual mandate.

This strikes me as a concession to reality on Obama's part — both political reality and policy reality. It's also good news. Regardless of the details, I think it's important to commit to the principle of universality in a concrete way, and an individual mandate is one way to do that. It's not the way I'd do it, but at least once the principle is in place it makes it a lot easier to argue productively over the details. So two cheers for the mandate. It's a pragmatic and welcome shift.